It was reported that a mitraclip procedure was performed to treat functional mitral regurgitation (mr) with a grade of 4.A mitraclip xtw was implanted without issues.To further reduce mr, a mitraclip xt was inserted, and grasping was performed, but difficulties capturing the leaflets occurred, and a tear in the anterior mitral leaflet (aml) was observed.In the physician's opinion, the tear was caused from turning the clip toward the posterior leaflet while keeping the anterior leaflet gripper down.Therefore, the clip was removed from the patient.The procedure was completed with one clip implanted, reducing the mr to a grade of 3.There was no clinically significant delay in the procedure.
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The device was not returned for analysis.A review of the lot history record revealed no manufacturing nonconformities issued to the reported lot that would have contributed to this event.Additionally, a review of the complaint history identified no similar complaints reported from this lot.The investigation determined the reported positioning failure of inability to capture the leaflets appears to be related to tissue injury (anterior leaflet to tear).The reported tissue injury appears to be due to procedural condition.Tissue injury is listed in the instructions for use as a known possible complication associated with mitraclip procedures.The reported serious injury/illness/impairment was a result of case specific circumstance as no treatment was provided for the tissue injury.There is no indication of a product issue with respect to manufacture, design, or labeling.
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